Endgames case report: “A series of unfortunate events”

A 24 year old man presented to the accident and emergency departmentbecause he had been planning to take an overdose, but had decidedinstead to seek help from mental health services. He had intendedto take the contents of several blister packs of paracetamol,together with alcohol. He had been having suicidal thoughtsfor a week but they had become particularly pronounced overthe past two days.

His recent history was one of a “series of unfortunate events”that had left him feeling desperate. Four months ago his flatmatestole money from him, which meant that he was unable to repayseveral loans. His debtors had started to threaten him and hehad been forced to move to a different city and leave his job.He had become socially isolated, and continuing financial difficultieshad resulted in poor relations with his new landlord. Just beforehis presentation he had been awaiting a cheque for housing benefit.However, this had not arrived, and he described this as “thelast straw.” He reported feelings of hopelessness and thoughtsof “what’s the point?”

He had no history of suicide attempts, self harm, or suicidalthoughts. Five years previously, however, he was admitted twiceto a psychiatric ward with psychotic symptoms associated withthe use of cannabis. Currently there is no evidence of psychosis,and no relevant medical history. He came to hospital on hisown, but a friend provided a collateral history on the telephone.The patient says that if he goes home he is worried that hewill take the large amount of paracetamol tablets that awaithim there.

Questions

1 How would you assess his risk of suicide?

2 How would youmanage this patient?

3 What are the general principles ofsuicide prevention?

Answers

1 How would you assess his risk of suicide?

Short answer:
The likelihood of future suicide should be estimated duringan unhurried and sympathetic interview by establishing the motivationfor, and circumstances of, the suicidal ideas or act in question,as well as the presence of known risk factors. It is usefulto obtain a collateral history from a friend or relative ifpossible. The three most important risk factors for future suicideare current suicidal intent, history of suicide attempts, andpresence of a psychiatric disorder. Once you have inquired afterrisk factors and have an understanding of the patient’scircumstances you should be able to form an opinion on the patient’ssuicide risk.

Long answer:
A suicide risk assessment is normally performed in hospitalby psychiatric trainees or psychiatric liaison nurses, althoughknowledge of risk assessment with suicidal ideation is usefulfor doctors working in all specialties. This answer is writtenfrom the perspective of a psychiatric trainee conducting anassessment in hospital, but assessments elsewhere and underother circumstances follow the same principles.

Before assessing a patient you should establish his or her stateof physical health and, if appropriate, level of intoxication.The appropriateness of assessing a patient who is physicallyunwell, or compromised through drug or alcohol use, is oftena cause of friction between psychiatric and non-psychiatricprofessionals. It may be wise not to see patients who are acutelyphysically unwell until they have improved, because their physicalhealth may be a more pressing concern and may prevent a satisfactoryassessment. However, if the patient is physically stable, thentheir physical problems need not be a barrier. Although it maynot be safe to wait until someone is no longer intoxicated beforethey are seen, an assessment of mental state performed underthese circumstances should ideally be repeated.

When assessing a patient for suicide risk your main task isto gather information that will help you decide whether a futuresuicide attempt is likely. The first major area to cover inthe assessment is the context in which the patient’s suicidalact took place and the motivation behind it. This involves adetailed review of events leading up to the act, the act itself,and the circumstances under which the patient came to hospital.Life events typically precede suicidal acts, with disruptionof a relationship with a partner being particularly common.1The features of the circumstances surrounding the act providean indication of seriousness and hence chance of it being repeated.The table lists features of an attempt that suggest high andlow risk of repetition.

Once the circumstances surrounding a suicidal act have beenestablished, specific risk factors for future suicide must beexplored.

The main risk factors indicating continued high risk are:

A statement of continued intent. Although clinicians may bereluctant to ask such a blunt question, patients are often surprisinglyopen about their current state of mind.

History of previoussuicidal behaviour. Many people who completesuicide have madea previous attempt, and a history of selfharm or suicide attemptsis present in at least 40% of cases.3 You will need to ask detailsabout previous attempts, suchas whether hospital admissionwas necessary?

Presence of a psychiatric disorder. About90% of people whohave completed suicide have a psychiatricdisorder at the timeof death.3 Affective disorder carries thehighest risk of suicide,followed by substance misuse (especiallyalcohol), and schizophrenia;comorbidity greatly increases risk.3 A key factor linking depressionto suicidal acts is hopelessnessor pessimism about the future,and this should be included inthe history taking.4

To establish the presence of a psychiatric disorder an assessorshould inquire after the common symptoms of psychiatric disease,any contact with mental health services, and whether any psychiatricdrugs are being prescribed. Clinical descriptions and diagnosticguidelines for mental and behavioural disorders are found inICD-10 (International Classification of Diseases, 10th revision).5

Once these three main risk factors have been dealt with, furtherrisk factors associated with suicide are:2

Age 25-54 years

Male sex

Unemployed or retired

Poor physicalhealth

Separated, divorced, or widowed

Living alone

Lowersocioeconomic class

Criminal record

History of violence.

Scales are available to help assess the risk factors for suicide,such as the Beck suicidal intent scale6 and the SAD PERSONSscale,7 which has a mnemonic that is easily remembered.

Other areas that must be covered during an assessment includethe patient’s medical history, medications, and familyhistory of medical or psychiatric disease. A suicide attemptcan be a response to stress learnt by example, and a familyhistory of suicide increases the risk at least twofold, independentlyof family psychiatric history.8 Personal history should alsobe sought and include schooling, accommodation, personal relationships,and employment.

It can be useful to talk to a friend or relative to gain a collateralhistory. When taking such a history, the assessor must rememberto respect the patient’s confidentiality. Collateral historyis especially valuable if the patient is deliberately tryingto mask his or her mental state and seems to be telling youwhat he or she thinks you want to hear rather than how theyactually feel. It is also necessary to evaluate the degree ofsupport available to the patient should they return home. Ifthe patient’s suicide attempt seems to be as a resultof a situation at home to which they are proposing to return,this would obviously be of concern.

If in doubt about a patient’s level of risk it is wiseto consult a more experienced colleague.

2 How would you manage this patient?

Short answer:
It may be possible to discharge patients who are thought tobe at low risk to the care of their general practitioner forfollow-up, whereas those with moderate risk will probably needan urgent appointment with a community mental health team orinvolvement of a home treatment team. Patients thought to beat high risk may need hospital admission and possible assessmentunder appropriate mental health legislation. Follow-up serviceswill consider whether further interventions—for example,psychotherapy and pharmacotherapy—are appropriate. Thispatient was thought to be at moderate risk because of continuingsuicidal intent and access to lethal drugs. He was admittedinformally to a psychiatric inpatient unit.

Long answer:
It is important to make thorough notes on your consultation.Although this is true for any patient encounter, it is evenmore important here because your record serves as potentiallyvaluable material for future risk assessments should the patientattempt suicide again. The steps taken to protect the patientshould also be documented.

Suicidal acts occur for a variety of reasons, and often theprimary aim is not death but some other outcome, such as demonstratingdistress to other people or seeking change in their behaviour.9 Therefore, the needs of individual patients will vary widely.If you have asked about the risk factors above and have an understandingof the context of the suicidal act then you will have formedan opinion as to a patient’s suicide risk. Any patientwith a concerning level of perceived suicide risk will, fora time, need supervision and restriction of access to lethalmeans. Your assessment will establish to what level and forhow long these restrictions should be enacted.

If you think that a patient’s suicide risk is low andyou are assured that they have good support in the community,they can be discharged from hospital and followed up by theirgeneral practitioner or community mental health team, to whoma copy of your assessment should be sent. A patient dischargedhome should be advised to attend appropriate services, suchas the accident and emergency department, if they or their familyare concerned in the future.

You may feel that the suicide risk is moderate. This might bethe case for patients who say that they have no continuing suicidalideation, but in whom you have identified several risk factorsfor a further attempt. In this situation, although it may beappropriate to discharge the patient from hospital, the localcommunity mental health team should be urgently informed sothat they can provide follow-up. Some psychiatric home treatmentteams will be willing to see patients at this level of risk.

For any patient you discharge who has had recent suicidal thoughtsor has performed suicidal acts you must be convinced that theenvironment to which they are discharged will be safe and supervisedby friends or relatives whom you judge to be reliable, who wishto care for the patient, and who understand their responsibilities.

An example of a patient who is at high suicide risk would besomeone who continues to have suicidal intent, has made severalprevious attempts, and has a psychiatric disorder. Hospitaladmission is appropriate for such patients. If they refuse theoffer of an informal (non-compulsory) hospital admission, youmay wish to recommend that they are detained under the relevantmental health legislation.

After their assessment it is the responsibility of the assessingdoctor to be confident that, before the end of their shift,the appropriate follow-up services will be provided with allthe information that is needed.

3 What are the general principles of suicide prevention?

Short answer:
Two broad approaches to reducing the total number of suicidesexist. The first is to take steps at a population level; anexample of this is to sell paracetamol in smaller size packs.The second involves targeted strategies, such as evidence basedtreatments, aimed at high risk groups about whom healthcareprofessionals should be aware.

Long answer:
The two main approaches for reducing the number of suicidesin the population are: preventive strategies that can be appliedto the population as a whole and those that are targeted towardshigh risk groups.

Population strategies1011:

Improving the ability of primarycare doctors to recogniseand treat depression and other psychiatricdisorders has beenshown to be valuable because studies havereported that 16-40%of people who die by suicide have visiteda family doctor inthe week before their death.12

Schoolbased programmes aimedat improving psychological wellbeingcould contribute to suicideprevention in young people by increasingknowledge of psychologicalsymptoms and help seeking behaviour.

Gatekeepers are communitymembers, such as clergy, whosecontactwith potentially vulnerablepopulations provides anopportunityfor them to help identifyat risk individuals andthen directthem towards appropriateassessment and treatment.

Publiceducation campaigns havebeen aimed at improving understandingof the causes and riskfactors for suicidal behaviour and reducingthe stigmatisationof mental illness and suicide, with the aimof improving therecognition of suicidal risk and increasinghelp seeking.

Restricting the availability of the meansby which peoplecommitsuicide, such as installing safety barrierson bridges,saveslives. Substitution of one method for anothercan happen,butstudies indicate that many people have a preferencefora givenmethod.13

The media can help educate the publicabout suicide,but itcan exacerbate matters by glamorisingsuicide. Restrictionson reporting and codes of conduct canhelp lower suicide rates.

Strategies applicable to high suicide risk groups1011:

Some people are at particular risk of suicide, and healthcareprofessionals should provide these people with treatments thatreduce the risk of suicide attempts. Patient groups at particularrisk of suicide include people with psychiatric disorders—thosewho have just been admitted or just been discharged from psychiatrichospital in particular; elderly people; high risk occupationalgroups, such as medical practitioners, pharmacists, farmers,and vets; and prisoners. Major risk factors for suicide in prisonersare previous attempts, recent suicidal ideation, being in asingle cell, presence of a psychiatric disorder, and a historyof alcohol problems.

Psychiatric disorders should be treatedin high risk patients,and pharmacotherapy and psychotherapyare key treatments. Becauseof the chronic and recurrent natureof mental illness, and thedifficulties in engaging patientswith treatment, the best possibleacute and long term psychiatriccare needs to be available.

Even with near perfect careand risk assessment, and despitethe best efforts of friendsand professionals, suicide is notsomething that can be entirelypredicted or prevented.

Patient outcome

Our patient was judged to be of moderate-high risk of futuresuicide. He had been having suicidal thoughts for some timeand had a method in mind. If he had been discharged he wouldhave returned to an unresolved stressful social situation withcontinued access to lethal methods. Particular risk factorsfor repeat suicide were a possible diagnosis of depression andstatement of continued intent. Other risk factors were malesex, social isolation, and unemployment. His friend confirmedhis story and said that he had seemed to be low in mood recently.

We thought that there was sufficient cause to warrant an informalinpatient hospital admission. The admission lasted three days,during which time antidepressants were started, his relationshipwith his landlord improved after the intervention of a socialworker, and he denied further suicidal ideation. At the endof his stay he was discharged into the care of a community mentalhealth team.

Further reading

The reader is referred to the relevant NICE guidelines on assessmentand management of self harm.14

References

Cavanagh JTO, Owens DGC, Johnstone EC. Life events in suicide and undetermined death in south-east Scotland: a case-control study using the method of psychological autopsy. Soc Psychiatry Psychiatr Epidemiol 1999;34:645-50.[CrossRef][Web of Science][Medline]

National Institute for Health and Clinical Excellence. Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. 2004. www.nice.org.uk/CG016NICEguideline.

I wrote a post about rational suicide a few weeks ago which attracted a lot of interest, and even spawned a post on another site dedicated to debunking my viewpoint. This issue and that of physician assisted suicide is rarely far from the headlines and clearly is a subject which excites strongly held opinions. Most recently conductor Sir Edward Downes and his wife are reported to have died together at the controversial Swiss assisted suicide clinic Dignitas. For a small organisation it attracts an impressive amount of coverage and its actions may have a substantial influence on future UK legislation.

For many people the discussion of the right to die is a simple one: people should not have to suffer toward the end of their lives and have the right to choose the time and means of their own passing. This attitude is in line with the increasing emphasis on choice and self determination in our society of which suicide is perhaps the ultimate expression. There are strong emotions involved and polarized viewpoints, but shouldn’t mean that we shy away from discussion both about philosophical underpinnings as well as more practical aspects.

I am concerned that where assisted dying to become legal in this country doctors would be expected to take a central role and this would sit unhappily with our usual duties. Psychiatrists would regularly be called up to make difficult assessments about capacity and some of us might find being asked to assist in someone’s death very distressing. Outside these professional concerns, and more fundamentally, is the message that legalised assisted dying would send out to vulnerable people who are near to the end of their lives. Elderly people may worry that they are a burden or that their care is costing too much, and with a legal way of reaching a swift resolution may feel a duty to move on. I cannot see how we could safe guard against this.

Sir Edward was elderly and frail but not terminally ill when he chose to take his life. Apparently decided that he could not live without his wife and choose to end his life when she was choosing to end hers. Most discussion about assisted suicide has focused on incurable conditions, which Sir Edward did not have. Enabling people in similar situations to Sir Edward to take their own lives is disquieting to me.

Someone called Cliff Arnall has come up with a equation for the most depressing day of the year. It goes like this:

1/8W+(D-d) 3/8xTQ MxNA.

Where W is weather, D is debt – minus the money (d) due on January’s pay day – and T is the time since Christmas. Q is the period since the failure to quit a bad habit, M stands for general motivational levels and NA is the need to take action and do something about it.

I was rather amused by this the first time I read about it. The Guardian had an article all about the best songs to listen to on the most miserable day of the year. But it’s all bollocks, so much so that it is worthy of a diatribe from Bad Scientist writer Ben Goldacre, who appears to be a longtime adversary of Mr Arnall. The same story was wheeled out in 2005 and 2006
The Samitarians got sucked this time and have launched Beat Blue Monday as a money earning drive, allegedly with Mr Arnall and a PR company taking their cut.

So when is the most depressing day of the year? If we assume that people who commit suicide are a reliable indicator of misery, then these two papers are relevant:

The Office of National Statistics have published a cheerful paper entitled Mortality from suicide and drug-related poisoning by day of the week in England and Wales, 1993–2002 An increased proportion of suicides occurred on Mondays, while the single day on which the largest number of suicides occurred was 1st January 2000, a Saturday. The increased numbers of deaths would on a Monday and especially on 1st January would suggest a theory that people are more suicidal with the move into a new time period.

More light is shed by another interesting article which considers the frequency of suicide by day, day of the week, month, and lunar phase by studying suicide occurrence among residents of Sacramento County, CA, during the period from 1925 to 1983. It found suicide occurrence varying substantially by time of day, with the fewest suicide deaths occurred during the early morning hours. Suicides occurred most frequently on Monday for both males and females and for most age groups. Furthermore, variation by month followed no consistent pattern by gender, age, years of the study. Suicide occurrence did not vary by lunar phase.